This position is accountable for managing all Medicare reconsiderations, grievances and appeals, in accordance with company policy and the Centers for Medicare and Medicaid Service (CMS) regulatory requirements. This position serves as the CMS regional office’s contact for appeals, grievances, and complaints. This position requires a strong working relationship with internal and external business partners. This person requires the ability to work independently under tight timeframes with minimal supervision. This position will analyze, research, document, track, and resolve medical and prescription drug appeals and grievances within the required timeframes including providing the resolution to all appropriate parties as well as preparing and submitting appeals to the IRE. This position requires the ability to communicate effectively, both in writing and verbally, with members, providers, and other contacts including CMS, Medical Directors, and management staff throughout the organization to ensure concise, grammatically correct correspondence to ensure understanding of the recipient. This position will assist in the preparation and presentation in ALJ, MAC judicial hearing, and CMS audits. This person will identify and analyze trends and emerging issues and recommend solutions. This person will pull reports in accordance with CMS regulatory requirements and the needs of the department.
Job Title: Coordinator Grievances and Appeals
Clinic Location: Pearland Administrative Office Building
Department: KS Plan Advantage-Ops
Job Type: Full Time
Salary Range: $48,755.00 – $60,237.00 (Pay is based on several factors including but not limited to education, work experience, certifications, etc.)
Required: Bachelor’s degree or equivalent experience or combination of education and experience.
Preferred: Associates or bachelor’s Degree
Required: 1-2 years Managed Care experience in a managed care environment or in appeals and/or grievances.
Preferred: Medicare Advantage experience processing quality of care complaints, internal and external expedited appeals, and IRE determinations
Medicare Part D experience
Process Improvement Experience and ability to proactively identify issues and /problems
Preferred: Knowledge of claims and coding
Required: PC skills, Word, Excellent Data Entry Skills, Data Entry high level proficiency
Preferred: Effective organizational skills, and ability to work independently
Required: Ability to communicate readily and easily. Excellent written and verbal communication skills. Analytical and customer service orientations are essential.
Preferred: Ability to analyze data
Working Environment: Office
Start your career journey and become a part of a community of renowned Healthcare professionals. Kelsey-Seybold Clinic is Houston’s fastest growing, multispecialty organization with more than 40 premier locations and over 65 specialties. Our clinics are comprised of more than 600 physicians and as we continue to grow, our focus is providing quality patient care by adding to our team of clinical and non-clinical professionals that work together in a convenient, coordinated, and collaborative manner. Enjoy the rewards of a successful career while maintaining a work/life balance by joining our team today and changing the way health cares.
Why Kelsey-Seybold Clinic?
- Medical, Vision, and Dental
- Tuition Reimbursement
- Company Matching 401K
- Employee Reward and Recognition Program
- Paid time off for vacation, sick, and holidays
- Employee Assistance Program
- Continuing Medical Education allowance